2024 FSA Podium and Poster Abstracts
P015: PREOPERATIVE CONSIDERATIONS FOR RIGHT VENTRICULAR DYSFUNCTION - A CASE REPORT
Ryan J Lorenzo, DO, MBA; Alex Hendon, DO; Imani Thornton, MD; Westside Regional Medical Center
Introduction: Right ventricular (RV) dysfunction is increasingly becoming an area of interest in the perioperative arena. Defined as any abnormality in RV structure or function, it can be further subdivided into three distinct physiological categories including RV pressure loading, RV volume loading, and impaired RV contractility.1 Regardless of the underlying mechanism, all causes of RV dysfunction are independently associated with poor clinical outcomes.2,3
Case Background: A 71-year-old female presented to the emergency department status post mechanical fall from her bed. Lumbar spine MRI showed acute T12 superior endplate fracture with grade 1 spondylolisthesis at L4-5. Patient was evaluated by neurosurgery and plan was to proceed with L4-5 transforaminal lumbar interbody fusion (TLIF) when patient was determined stable. Cardiac workup was requested.
Clinical Course: Significant medical history included neuropathy, rheumatoid arthritis, glaucoma, and chronic low back pain. Functional status was difficult to ascertain as patient activity was limited by chronic back pain.
Initial echocardiogram showed left ventricular ejection fraction (LVEF) of 60%, with mildly increased wall motion and mild concentric hypertrophy. There was a secondary finding of an ‘unidentifiable pressure point from outside of the right ventricle pushing in.” A follow up echocardiogram was ordered to re-evaluate RV wall motion specifically. This echocardiogram determined that the RV free wall appeared aneurysmal in an area measuring 1.5 cm. See Figure 1,2 below.
Considering that the patient was stable and clinically improving, the decision was made to not go forward with the TLIF as inpatient. She was discharged home with the plan to follow up as outpatient for cMRI and coronary CTA for further evaluation of her RV dysfunction and coronaries prior to neurosurgical intervention.
Discussion: In a patient with unknown cardiac history, a noninvasive transthoracic echocardiogram is an essential component of a cardiac workup per the American College of Cardiology/ American Heart Association (ACC/AHA) guidelines.4 In this case, the findings of RV dysfunction precluded the patient from undergoing surgery. As stated previously, RV dysfunction falls into three distinct physiological categories - RV pressure loading, RV volume loading, and impaired RV contractility. As demonstrated by the aneurysm measuring 1.5 cm along with elevated RVSP, a patient can fall into more than one category. This patient likely has both RV pressure loading and impaired contractility.
Conclusion: The decision not to proceed with surgery was a multidisciplinary effort to ensure the safety of the patient. As initially put forward, all causes of RV dysfunction are independently associated with poor clinical outcomes. Whether findings include reduced ejection fraction, underlying valvular disease, pericardial effusion, or - as in this case – RV aneurysm, an echocardiogram can reveal underlying disease processes that can profoundly change the management of a patient not only in the operating room but perhaps more importantly before they get there.
Figure 1. Parasternal Long Axis (PLAX) in Systole showing RV aneurysm.
Figure 2. Parasternal Long Axis (PLAX) in Diastole showing RV wall abnormality